App-Permit-Compliance / 295air ....
No:.. ...._..._ Fitz ..... ....................
THE COMMONWEALTH OF MASSACHUSETTS
--�-� BOARD OF HEALTH
ICJ�V U................ ..............X.sLrmouth........................................_........
.lppliration for Uhipoottl Varkfi Tomlitrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Fruean Ave Lot 10&11
................ ___............................................................................ ............. ........................................ .............................................
Location • Address or Lot N.
,BxIewer•.Realty„_Trust 100 Old Town House Road S.Yarmouth,Ma
................................ ...................... .......
owner Address
W C Csn�t. ' ......:2:!gc.............-r`'..Y5.4 -� �i �'� � a............................... t
t� Installer I Address
6 Type of Building Size Lot ...........................Sq. feet
aDwelling —No. of Bedroomssteel O -- --... Expansion Attic ( ) Garbage Grinder ( )
pa Other —Type of Building .......................... Not. of persons ..... _..................... Showers ( ) — Cafeteria ( )
P 1� Lavatories
Otherfixtures ----------------------------......... _.................. - .................................... ........ .................................
W Design Flow............................................gallons per person per day. Total daily flow ............ ................................ gallons.
WSeptic Tank —Liquid capacity ............ gallons Length ................ Width................ Diameter................ Depth................
x Disposal Trench — No ..................... Width.................... Total Length.................... Total leaching area,. .................. sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area... ............... sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by ........................................... Date................
N Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water
W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water,
Ri........................................................................................ .......... .................................
0 Description of Soil ........ ....... .................................. ........................................... .........................................,
M
w
M.. ...................................................................................................... ..........---------------------...---------------------- ..---------
.....
UNature of Repairs or Alterations — Answer when applicable.......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL.e 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
p operation until
%a/]Certificate f Compliance has been issued by the board of health.
(-�"��e`.'Q" _ Signed..._ ...... ....... S �.2 - 8(6
P t\ ..
Dat
Application Approved By.......................... -- -------- %!�' r V
��
•.....
xte
Application Disapproved for the following `reasonr:....... '-------------------------....---....----................... ----------------•---•----................
Permit No.....Sr'.� :..... �� G{..-S................... Issued ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAROF HEALTH
............................. OF.'t,a g+,.n.....:.......................................I....................
(9rdifiratr of Tomplittnre
THIS IS, TO CERTIFY, That the Individual Sewage Disposal System constructed ('{ `,) or Repaired ( )
by.. " '. '•-------------•-•----..._............. ...------...---------------------•--------------•----------•--...-----.........................._.....
has been installed in accordance with the provisions of rJTJL 5 of The State Sanitary//Cadej�ts described in the
application for Disposal Works Construction Permit No�.'..��.t::.. %' + .........'.2 . dated,'C';: , a ra....... -'-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.,A GUARANTEE THAT THE
SYSTEIef;tWILL FUNCTION SATISFACTORY.
DATE .. .`..!... ),.,.`>;4 ............................... Inspector,...t-.. r ;r t